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Objective:To evaluate the outcome of laser coagulation under fetoscope for placental chorioangioma (CA).Methods:The clinical data of three pregnant women with giant CA treated by laser coagulation under fetoscope in Peking University Third Hospital from January 2018 to December 2020 were analyzed retrospectively. Relevant articles up to September 2022 were retrieved from Wanfang Database, China National Knowledge Infrastructure and PubMed, and the clinical data of all patients were retrospectively summarized. Indications and intervention effects of fetoscopic laser therapy were analyzed. Descriptive statistics was used to describe the data.Results:Thirteen patients were involved in this study including 10 cases retrieved from the databases. The average age of the pregnant women was (30.3±6.2) years old. There were 12 cases of single pregnancy and one case of twin pregnancy (monochorionic diamnionic twin pregnancy). Except for cases for which data were not available in the literatures, at the diagnosis of CA, the average gestational age was (19.9±4.5) weeks ( n=7) and the average maximum diameter of the mass was (6.1±4.1) cm ( n=6). The patients underwent fetoscopic laser therapy at an average gestational age of (25.0±2.0) weeks ( n=13) with the average maximum tumor diameter of (7.6±2.8) cm ( n=9). After treatment, the amniotic fluid volume of three cases decreased to normal. In one case, the amniotic fluid volume decreased but was still above the upper limit of the normal range. Moreover, the maximum tumor diameter decreased in four cases; the peak systolic velocity of the fetal middle cerebral artery decreased to normal in one case; fetal heart function became normal in two cases and fetal edema was relieved in one case. Among the three patients treated in our hospital, the blood supply of CA disappeared after treatment. Intrauterine fetal death occurred in two cases. The other 11 patients gave birth to live babies at the gestational age of (36.6±3.8) weeks with five through cesarean section (5/11), five through vaginal delivery (4/11) and two not reported. The birth weight of the neonates was (2 712±1 023) g and all of them survived. The gender of five neonates were reported and all were females, two of them were monochorionic diamnionic twins. No abnormality was found in the three neonates delivered in our hospital during a six-month follow-up. No abnormality was reported in the other neonates during ten days to six months of follow-up. Conclusions:Fetoscopic laser coagulation may help reduce the size of CA, decrease complications and improve pregnancy outcomes.
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Objective:To investigate the short- and long-term outcomes of fetuses with selective fetal growth restriction (sFGR).Methods:A retrospective study was conducted on monochorionic diamniotic (MCDA) twins with sFGR admitted to the Neonatal Intensive Care Unit of Peking University Third Hospital from September 2017 to December 2019. MCDA neonates delivered during the same period without significant complications were selected as the control group. MCDA twins with sFGR were divided into type Ⅰ, Ⅱ, and Ⅲ groups and then further divided into the larger and the smaller fetus subgroups according to the birth weight. These children were followed up by telephone at 2-3 years old. Height-for-age and weight-for-age Z-scores were calculated. Ages and Stages Questionnaire-Third Edition (ASQ-3) was used to determine comprehensive development. Independent sample t-test, one-way analysis of variance, non-parameter test, and Chi-square test (or rank-sum test) were used for statistical analysis. Results:(1) A total of 116 pregnant women with sFGR (232 neonates) were enrolled in this study. There were 43, 40, and 33 mothers and 86, 80, and 66 newborns in type Ⅰ, Ⅱ, and Ⅲ groups, respectively. The control group included 31 pregnant women and 62 neonates. The gestational age at onset of sFGR was younger in the type Ⅱ and Ⅲ groups than in type Ⅰ group [(23.8±4.8) and (24.1±3.1) vs (27.0±6.1) weeks, F=5.19, P<0.05; all P<0.017 during pairwise comparisons]. (2) The incidence of sepsis and treatment abandonment/death in neonates in type Ⅱ and Ⅲ groups were higher than those in type Ⅰ and control groups [neonatal sepsis: 11.3% (9/80) and 6.1% (4/66) vs 2.3% (2/86) and 0.0% (0/62), χ2=6.30, P=0.001; death or treatment abandonment rate:13.8% (11/80) and 10.6% (7/66) vs 3.5% (3/86) and 0.0% (0/62), χ2=4.68, P=0.003; all P<0.017 during pairwise comparisons]. In cases with type Ⅱ or type Ⅲ sFGR, the risk of digestive system diseases was significantly higher in the smaller fetus group than in the larger fetus group [type Ⅱ: 46.2% (37/80) vs 38.7% (31/80), χ2=16.72; type Ⅲ: 47.0% (31/66) vs 34.8% (23/66), χ2=39.69; both P<0.001], while the rate of respiratory system diseases was lower in the smaller fetus group [type Ⅱ: 35.0% (28/80) vs 45.0% (36/80), χ2=36.85; type Ⅲ: 37.9% (25/66) vs 45.4% (30/66), χ2=12.55; both P<0.001]. The incidence of neonatal sepsis in smaller fetuses was higher than that in larger ones in type Ⅱ sFGR [7.5% (6/80) vs 3.7% (3/80), χ2=4.68, P=0.034]. The incidence of neurological complications in larger fetuses was higher than that in smaller ones in type Ⅲ sFGR [15.1% (10/66) vs 4.5% (3/66), χ2=5.72, P<0.001]. (3) In type Ⅱ group, seven neonates died (one case of cerebral hemorrhage, two cases of gastrointestinal perforation, two cases of septic shock, and two cases of necrotizing enterocolitis), and four cases withdrew the treatment. In type Ⅲ group, four neonates died (two cases of necrotizing enterocolitis, one case of gastrointestinal perforation, and one case of cerebral hemorrhage), and three cases withdrew from the treatment. (4) Totally, 71 children in type Ⅰ, 61 in type Ⅱ, and 58 in type Ⅲ group were followed up at the age of 2-3. Children with type Ⅱ or type Ⅲ sFGR lagged behind those in type Ⅰ group and control group in physical growth [ M ( P25- P75), Z-scores:－0.46 (－0.87-0.42),－0.35 (－0.62-0.71), 0.05 (－0.61-0.51), and 0.14 (－0.57-0.75); H=6.20, P=0.001]. In type Ⅱ and Ⅲ groups, the smaller fetuses lagged the larger fetuses in physical growth at 2-3 years of age. ASQ-3 scores in communication, gross motor, fine motor, problem-solving and personal-social areas were all lower in type Ⅱ and Ⅲ groups than in type Ⅰ and control groups. ASQ-3 scores in the five dimensions of the smaller fetuses in the type Ⅱ group were lower than those of the larger fetuses. In the type Ⅲ group, the smaller fetuses had lower ASQ-3 scores in communication and gross motor than the larger ones [communication ability: (42.6±18.8) vs (56.4±9.4) scores, t=19.63, P<0.001; gross motor: (45.5±19.7) vs (54.5±9.7) scores, t=12.64, P=0.003]. Conclusion:The neonatal morbidity is significantly increased in type Ⅱ and Ⅲ sFGR, and babies lagged others in height, weight, and ASQ-3 score at 2-3, which is worthy of early attention.
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Objective:To analyze the clinical value of noninvasive prenatal testing (NIPT) in vanishing twin (VT) pregnancies.Methods:A total of 164 VT pregnancies that underwent NIPT in Peking University Third Hospital from January 2017 to December 2020 were enrolled. Gestational age at onset of vanishing, results of NIPT and invasive prenatal diagnosis, blood sampling time points, and pregnancy outcomes were retrospectively analyzed using two independent samples t test and Chi-square test. Results:(1) Of the 164 cases, six had positive results for NIPT, but negative results for karyotype analysis or single nucleotide polymorphism genotyping, with a false positive rate of 3.7% (6/164) for NIPT and all of them were delivered at term. Four pregnancies terminated in the second trimester, including two fetal malformation cases and one unexplained intrauterine death whose single nucleotide polymorphisms results are all normal and one inevitable abortion case due to premature rupture of membrane who refused amniocentesis. The other 154 women all gave birth to normal phenotype babies including 12 preterm ones. (2) The false-positive rate of NIPT was lower in VT pregnancies diagnosed at less than eight gestational weeks than those diagnosed after [1.5% (2/134) vs 13.3% (4/30), χ2=6.68, P=0.010]. The false-positive rate was 6.9% (4/58) in women diagnosed at or below eight weeks between the occurrence of VT and blood sampling and was 1.9% (2/106) in those with interval more than eight weeks, but without significant difference ( χ2=1.44, P=0.231). Conclusions:Although VT pregnancies exist false-positive results in NIPT, screening is still recommended based on fully informed consent to reduce unnecessary invasive prenatal diagnosis. The earlier the onset of VT, the lower the NIPT false positive rate, but whether extending the sampling interval would reduce the risk of false-positive needs further study.
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Objective:To evaluate the effect of different superficial vascular patterns on pregnancy outcome and residual anastomosis following laser coagulation in placentae with twin-to-twin transfusion syndrome (TTTS).Methods:This study retrospectively collected and analyzed the clinical data and postnatal placenta perfusion characteristics of 57 cases of TTTS who received fetoscopic laser occlusion of chorioangiopagous vessels (FLOC) and delivered at Peking University Third Hospital from April 2014 to April 2019. According to the vascular pattern, all the cases are divided into four groups, which were parallel, staggered, mixed, and monoamniotic groups. Differences in the operation time and method, pregnancy outcome, and residual vascular anastomosis between the four groups were compared using analysis of variance, non-parametric tests, and Chi-square (or Fisher's exact) tests. Results:Among the 57 cases, the staggered, mixed, parallel, and monoamniotic types were accounted for 68.4%(39/57), 15.8%(19/57), 14.0%(8/57), and 1.7%(1/57), respectively. After exclusion of one case of monoamniotic type, gestational weeks at onset and surgery in the parallel group were both later than the staggered and mixed groups [23.0 (22.0-26.3) weeks vs 21.0 (17.0-24.7) weeks and 22.6 (21.3-23.9) weeks, H=10.306, P=0.006; 25.0 (22.6-26.3) weeks vs 22.0 (17.4-24.9) weeks and 23.2 (22.4-24.0) weeks, H=9.926, P=0.007; all P'<0.016 7]. There was no statistical significance in the differences in operation time and method, gestational age at the end of the pregnancy, neonatal birth weight, or birth weight discordance between the three groups. The diameter of residual vascular anastomosis of women in the staggered group was less than that in the mixed group [0.6 (0.1-5.0) mm vs 1.4 (0.3-5.1) mm, P'<0.016 7], but no significant difference was observed in the parallel-group [0.9 (0.2-3.6) mm] neither with the mixed or staggered group. The staggered group was noted for an increased distance ratio of umbilical cord insertion compared with the parallel and the mixed group [0.66 (0.59-1.00) vs 0.49 (0.25-0.55) and 0.48 (0.42-0.53); P'<0.016 7]. There was no significant difference between the parallel and the mixed groups. Conclusions:Placental superficial vascular patterns may affect the residual vascular anastomosis in women with TTTS following FLOC, which should be thoroughly evaluated before the operation to develop an individual management plan to reduce residual anastomosis incidence.
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Objective:To analyze fetoscopic cord laser therapy for management of monochorionic monoamniotic (MCMA) twin pregnancies.Methods:The clinical data of fetoscopic cord laser therapy, including cord occlusion, transection, and disentanglement in three pairs of MCMA twins from January 2020 to January 2021 in Peking University Third Hospital were summarized. Literature on cord occlusion and/or transection in MCMA twins were retrieved from Cochrane Library, PubMed, EMBASE, CBM, WanFang, and CNKI from the time at establishment to December 2020. The clinical conditions, surgical indications and methods, disease progression, and maternal and infant prognosis were analyzed.Results:Three cases of MCMA twins in this study period received fetoscopic cord laser therapy between 17-24 weeks, among which two cases gave birth at full-term without any maternal or infant complications, and one was terminated due to fetal malformation. Seven English articles including 29 MCMA twin pregnancies were retrieved. In addition to the three cases reported in this article, a total of 32 cases were analyzed. The indication of cord occlusion and/or transection included twin-reversed arterial perfusion sequence (21.9%, 7/32), fetal malformation (46.9%, 15/32), selective fetal growth restriction (sFGR) (21.9%, 7/32), twin-to-twin transfusion syndrome (TTTS) (3.1%, 1/32), TTTS combined with sFGR (3.1%, 1/32), single intrauterine death (3.1%, 1/32). Gestational age at surgery was between 14 +1 to 27 +3 weeks. No maternal complication due to the operation was reported. After exclusion of two cases who did not receive cord transection and one case was terminated due to fetal malformation, all the other 29 co-twins were born alive at the gestational age between 24 +3 to 40 weeks and birth weight between 800-3 800 g. Among the 29 live born babies, four died soon after birth with unclarified reasons in the literature and one was born with multiple malformations which were detected prenatally, and the other 24 neonates were healthy during the follow-up from 1 month to 9 years old. Conclusions:For MCMA twin pregnant women with umbilical cord entanglement or other indications for fetal reduction, cord occlusion, transection, and disentanglement using fetoscopic cord laser is safe and effective for protecting the surviving fetus.
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Objective:To summarize the pregnancy outcome of monochorionic triamniotic (MCTA) triplet pregnancy and its relationship with multifetal pregnancy reduction.Methods:This study retrospectively recruited 23 women with MCTA pregnancy who delivered at Peking University Third Hospital from January 1, 2012, to January 1, 2020. All 23 cases received regular prenatal examination at our hospital from the first trimester, who were divided into two groups: selective fetal reduction group (randomly reduced one fetus, n=8) and expectant group ( n=15). Pregnancy outcome was described in all participants, differences in maternal age, gestational weeks and outcomes were compared between the two groups. The selective fetal reduction group was further divided into two subgroups: first-trimester vacuum aspiration group ( n=3) and second-trimester radiofrequency ablation group ( n=5), to evaluate the differences in pregnancy outcomes. Two independent samples- t test and Fisher's exact test were used as statistical methods. Results:(1) There was no significant difference in the gestational weeks at the end of the pregnancy [(31.7±4.1) vs (28.8±8.8) weeks], preterm delivery after 32 weeks (9/15 vs 4/8), at least two surviving children (12/15 vs 4/8) and at least one surviving child (13/15 vs 5/8) between the expectant group and the selective fetal reduction group (all P>0.05). One case with twin-twin transfusion syndrome in the expectant group underwent fetoscopic surgery at 19 weeks of gestation and delivered three live infants through cesarean section at 33 +2 weeks due to premature rupture of membranes. One case with twin reversed arterial perfusion sequence at 17 weeks of gestation refused fetal reduction and gave birth to a child at 33 weeks when one fetus's heart stopped beating and one was acardia. (2) The first-trimester vacuum aspiration group and the second-trimester radiofrequency ablation group showed no significant differences in the average gestational weeks at the end of the pregnancy [(28.5±7.6) vs (28.9±10.4) weeks, t=1.145, P>0.05], or the rate of at least one (2/3 vs 3/5, Fisher's exact test, P>0.05) or two surviving children (2/3 vs 2/5, Fisher's exact test, P>0.05). No postoperative infection or amniotic fluid leakage was reported in the subgroups. Conclusions:The pregnancy outcome of MCTA triplet with fetal reduction is not different with expectant group.
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Objective:To investigate the effect of placental vascular distribution on residual anastomoses (RA) after fetoscopic laser occlusion of chorioangiopagous ressels (FLOC) for twin to twin transfusion syndrome (TTTS).Methods:A total of 57 cases of TTTS after laser surgery were retrospectively analyzed from April 2014 to April 2019 in Peking University Third Hospital. The patients were divided into RA group (24 cases) and non-RA group (33 cases) according to whether RA occurred in the placenta after laser surgery. The clinical characteristics, perioperative conditions, pregnancy outcomes and placental structure characteristics of the two groups were compared. Multivariate logistic regression was used to analyze the risk factors of placental vascular distribution for RA. The RA group was further divided into non-remission group and remission group, and the placental characteristics and pregnancy outcome of the two groups were compared.Results:(1)General clinical characteristics: the age, application of assisted reproductive technology, incidence of gestational hypertension, gestational diabetes mellitus, preoperative maximum amniotic fluid depth of the donor and recipient twins, Quintero stage and placental position of TTTS patients in the two groups were compared respectively, and there were no statistically significant differences (all P>0.05).The gestational age of patients received FLOC in the RA group was significantly higher than the non-RA group [(23.0±2.4) vs (21.9±2.7) weeks, P=0.033].(2) Perioperative conditions and pregnancy outcomes: the delivery gestational age of the RA group was significantly lower than that of the non-RA group (median:31.8 vs 34.4 weeks, P=0.002);The newborn birth weight in the RA group was significantly lower than that in the non-RA group [(1 648±597) and (2 013±481) g, P=0.003].The birthweight difference in the RA group was significantly higher than that in the non-RA group (median:0.30 vs 0.11, P=0.005). (3) The placental structure and the risk factors influencing RA happened: the differences in the proportion of four types of placental vascular distribution in the RA group and non-RA group were different significantly ( χ2 =10.214, P=0.012), with a detail of parallel type 29% (7/24) and 3% (1/33), staggered type 58% (14/24) and 76% (25/33), hybrid 8% (2/24) and 21% (7/33), monoamniotic membrane type 4% (1/24) and 0 respectively. Multivariate logistic regression analysis showed that parallel placental vascular distribution was an independent risk factor for RA after FLOC ( OR=24.5, 95% CI 1.7-336.2, P=0.017). (4) Placental characteristics and pregnancy outcomes in the remission and non-remission groups of the RA group: the incidence of three kinds of anastomoses, the total number, total diameter and proportion of RA, and the placental territory discordance ratio were compared between the two groups, and there were no statistical significances ( P>0.05);The birth weight difference ratio in the non-remission group was higher than that in the remission group (median:0.41 vs 0.28, P=0.036). Conclusion:The parallel type of placental vascular distribution may be an independent risk factor for RA in TTTS after laser surgery.
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Objective:To explore the possible factors leading to failure of cell-free DNA (cfDNA) testing in maternal peripheral blood and analyze the pregnancy outcomes of this group of pregnant women.Methods:This retrospective study involved 5 195 women who underwent cfDNA testing in Peking University Third Hospital from April 2017 to April 2019. Based on the first cfDNA testing results, clinical characteristics of the pregnant women with successful (success group, n=5 107) and failed (failure group, n=88) cfDNA testing were compared using Mann-Whitney U test and Chi-square test. Multivariate logistic regression was used to analyze the risk factors of cfDNA testing failure and the effect of body mass index (BMI) on the success rate, and evaluate the feasibility of re-sampling and the factors affecting the unsuccessful testing of a second sample. Results:The failure rate of first cfDNA testing was 1.7% (88/5 195). Successful cfDNA testing was achieved in 74 (87.1%, 74/85) of 85 re-sampling cases, while results of the other 11 cases (12.9%, 11/85) remained invalid. Thus, the final failure rate was 0.2% (11/5 195). Multivariate logistic regression revealed that increased maternal age ( OR=1.086, 95% CI: 1.023-1.152, P=0.006), BMI ( OR=1.083, 95% CI: 1.021-1.149, P=0.008) and twin pregnancies ( OR=3.093, 95% CI: 1.715-5.577, P<0.001) were the risk factors of cfDNA testing failure, while increased cell-free fetal DNA (cffDNA) concentration ( OR=0.758, 95% CI: 0.720-0.761, P<0.001) was a protective factor. The overweight (BMI: 25-29.9 kg/m 2) and obese (BMI≥30 kg/m 2) women were 3.626 ( OR=3.626, 95% CI: 2.298-5.724, P<0.001) and 4.064 ( OR=4.064, 95% CI: 1.779-9.284, P=0.001) times more likely to have failed cfDNA testing than those with normal weight (BMI: 18.5-24.9 kg/m 2), respectively. The success rate of re-testing decreased as the maternal BMI increased, regardless of the time interval between the two samplings ( OR=0.840, 95% CI: 0.699-1.245, P=0.065). Seven out of the 74 cases with successful results in re-testing were at high risk, including one 45,X and one 47,XXY, confirmed by karyotyping amniocentesis. Among the 11 pregnant women with a failed testing after second sampling, eight underwent prenatal diagnosis with normal fetal chromosome karyotypes, and the other three cases without prenatal diagnosis all gave birth to neonates with normal phenotype. There was no statistical difference in the incidence of pregnancy loss between the failure and success group [9.1% (8/88) vs 2.5% (128/5 107), P=0.090]. Conclusions:Pregnant women with advanced age and higher BMI, lower cffDNA fraction and twin pregnancies are more likely to fail in cfDNA testing. For obese women, blood sampling can be postponed to a larger gestational age to reduce the failure rate. For pregnant women with failed testing in first sampling, a re-sampling is recommended, moreover, prenatal diagnosis is necessary for those had high-risk results or failed in re-testing.
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Objective:To analyze the perinatal outcomes in different methods of multifetal pregnancy reduction in dichorionic triamniotic (DCTA) triplet pregnancy.Methods:A retrospective analysis was performed on 57 cases of DCTA triplets in Peking University Third Hospital from January 1, 2010 to January 1, 2020, including 27 cases in expectant pregnancy group and 30 cases in selective fetal reduction (FR) group. The selective FR group was further divided into 3 subgroups according to different FR methods:retaining monochorionic dichorionic (MCDA) group, retaining dichorionic dichorionic (DCDA) group, and retaining singleton group. The perinatal outcomes of expectant pregnancy group and 3 subgroups of selective FR group were compared.Results:The gestational weeks in selective FR group was (34.5±5.7) weeks, and full-term delivery rate was 53% (16/30), respectively higher than those of the expectant pregnancy group (29.9±6.0) weeks and 7% (2/27). The miscarriage rate of the selective FR group was 10% (3/30), lower than that of the expectant pregnancy group (33%, 9/27). The differences between the two groups were statistically significant (all P<0.05). The ratios of pregnancy complications and newborn admission to neonatal ICU (NICU) in the selective FR group were lower than those of the expectant pregnancy group (all P<0.05). In the selective FR group, the gestational weeks in retaining MCDA group (6 cases), retaining DCDA group (13 cases), and retaining singleton group (11 cases) were (32.2±4.3), (33.0±6.3), and (37.4±4.7) weeks; the miscarriage rates were 1/6, 1/13, and 1/11; the premature delivery rates were 4/6, 7/13, and 0/11; the full-term delivery rates were 1/6, 5/13, and 10/11; pregnancies with at least 1 survivor rates were 5/6, 12/13, and 10/11; NICU occupancy rates were 6/8, 9/18 and 0/10, respectively. The retaining singleton group had the highest rate of full-term delivery and the lowest rate of NICU occupancy. Compared with other groups, the differences were statistically significant (all P<0.05). The full-term delivery rate was significantly higher in the retaining DCDA group than that of the expectant pregnancy group ( P<0.05). Conclusions:The risk of DCTA triplet pregnancy is high. Reduction of the MCDA pair to singleton has the highest rate of full-term delivery and the lowest rate of NICU occupancy. For pregnant women who wish to retain twin pregnancy, the risk should be fully informed, and consider reduction of one fetus of the MCDA and retaining DCDA twins to continue pregnancy.
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Objective To analyze the clinical characteristics of structural malformations in one of monochorionic diamnionic twins (MCDA). Methods The clinical data of 77 MCDA patients with structural malformations diagnosed by ultrasound were retrospectively reviewed from January 2012 to May 2017. The distribution of structural malformations, prenatal chromosomal karyotyping and pregnancy outcomes were analyzed. Results (1)Among the 77 MCDA patients with structural malformations, the single malformation accounted for 79％(61/77), the multiple malformations accounted for 21％(16/77). And there were a total of 94 types of malformations, the top three malformations were neurological malformations (32％, 30/94), cardiovascular malformations (29％,27/94) and twin reversed arterial perfusion sequence (TRAPS;10％,9/94). (2)Among the 77 patients with structural malformation, 64 cases (83％, 64/77) were examined for fetal chromosomes, of whom 14 cases (22％,14/64) were examined for fetal chromosomes of both twins, with 1 case (1/14) of discordant fetal chromosome. (3)Among the 77 patients, 4 cases (5％, 4/77) with severe fetal malformations terminated pregnancy. Totally 29 cases (38％, 29/77) with severe malformations were treated with selective fetal reduction, among whom 7 cases (24％, 7/29) experienced unexplained fetal death within 24 hours after the operation;2 cases (7％, 2/29) happened inevitable abortion, and 2 cases (7％, 2/29) underwent unexplained fetal death during the late pregnancy. Of the remaining 44 patients (57％,44/77) with expectant treatment, 13 cases (30％, 13/44) occurred twin transfusion syndrome (Ⅱ-Ⅳ), and were treated with fetoscopic laser occlusion. Eight patients had 2 survival twins, 4 patients delivered 1 survival twin, and 1 patient had dead twins. Conclusions The most common malformations in MCDA twins are the nervous malformations, cardiovascular malformations and TRAPS. The chromosome karyotype of MCDA twins with structural malformations are sometimes discordant, and separate samling of the twins is suggested for prenatal diagnosis. Selective fetal reduction could be given to severe structural malformation in MCDA patients safely and effectively. For non-severe structural malformation in MCDA patients with twin transfusion syndrome, fetoscopic laser occlusion is safe and effective.
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Objective To evaluate the efficacy of fetoscopic laser occlusion of chorioangiopagous vessels (FLOC) in treatment of twin-twin transfusion syndrome (TTTS) and to investigate the incidence of TTTS complicated with selective intrauterine growth restriction (sIUGR) for better understanding the effects of sIUGR as a complication of TTTS on pregnancy outcomes. Methods A retrospective study was performed on 116 gravidas who were diagnosed with TTTS of Quintero stage Ⅰ - Ⅳ in Peking University Third Hospital from September 2008 to September 2014. Among them, 44 cases received FLOC therapy. The incidences of sIUGR in each Quintero stage of TTTS were analyzed. Pregnancy outcomes of those 44 cases treated with FLOC were observed and the differences among four stage groups were analyzed. Chi-square or Fisher exact test was performed for statistical analysis. Results (1) The survival rates of both twins from stage Ⅰ to Ⅳ groups were 4/7, 10/14, 5/19 and 3/4, respectively, with statistically significant difference (χ2=7.840, P=0.038), but that in stage Ⅲ group was lower than in stage Ⅱ group without significant difference (P'=0.008). Differences in the total fetal survival rate among the four groups were statistically significant [8/14, 75% (21/28), 32% (12/38) and 6/8, χ2=14.016, P=0.002]. The total fetal survival rate in stage Ⅲ group was significantly lower than that in stageⅡ group (P'<0.008). In patients with stage Ⅲ TTTS, those complicated with sIUGR, after receiving FLOC therapy, showed a lower total fetal survival rate than those without sIUGR [21% (6/28) vs 6/10, P<0.05]. (2) Among the 116 TTTS patients, there were 63 cases (54%) with sIUGR complication. Patients with sIUGR complication in TTTS stages Ⅰ to Ⅳ groups accounted for 40% (14/35), 48% (11/23), 78% (28/36) and 46% (10/22), respectively, and the differences were significant (χ2=11.963,P=0.007). The incidence of sIUGR in stage Ⅲ group was greater than that in stage Ⅰ group (χ2=10.482, P'=0.002), and those in both stage Ⅲ and Ⅱ groups were higher than in stage Ⅰgroup without significant difference. Conclusions TTTS patients in stage Ⅲ have lower survival rate of both twins and total fetal survival rates after FLOC therapy, which may be related to a higher incidence of concurrent sIUGR.
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Objective To investigate the clinical outcome and placental characteristics of spontaneous twin anemia-polycythemia sequence (sTAPS). Methods Twelve cases with sTAPS delivered in Peking University Third Hospital from May 2013 to August 2016. The data of ultrasound characteristics, gestational age at delivery, and 1 minute Apgar score were analyzed,retrospectively. Placental superficial vascular anastomoses, placental territory discordance and the ratio of umbilical cords insertion distance to the longest placental diameter were also analyzed. Results (1) Only 1 case of sTAPS was diagnosed prenatally, the others were diagnosed postnatally because the fetal middle cerebral artery(MCA) doppler was not measured regularly. Five cases were complicated with selective intrauterine growth restriction (sIUGR). The median gestational age at delivery was 32.8 weeks(31-37 weeks). The pregnancies were terminated because 3 cases were sIUGR typeⅠ, 1 case was sIUGR type Ⅱ, 1 case was sIUGR type Ⅲ, 2 cases were fetal distress, 2 cases were severe pre-eclampsia, 2 cases were premature rupture of membrane, 1 case was fetal hydrops with abnormal doppler waveforms of ductus venouses. (2) When 5 sIUGR cases were excluded, there was no difference between the twins in birth weight [1797 g(940-2620 g),1648 g(980-2500 g);P=0.688]. The hemoglobin (Hb) level in all donor was significantly lower than recipient(P=0.000)and the inter-twin Hb difference was 147.6 g/L (84.0-216.0 g/L). While the reticulocyte percentage in donor was significantly higher than recipient (P=0.013) and reticulocyte percentage ratio was 3.60 (1.04-7.50). Five donor newborns had neonatal asphyxia, including 1 severe asphyxia, while no asphyxia happened in the recipient twins. (3) Arterio-arterial (A-A) anastomoses, veno-venous (V-V) anastomoses, arterio-venous (A-V) anastomoses were found in 3, 1 and 11 placentas, respectively. The total number of anastomoses was 2 (1-5) and the total diameter was 1.1 mm (0.4-2.1 mm), including 0 (0-1) A-A anastomoses with 0.2 mm (0.0-0.9 mm) in diameter and 2 (0-5) A-V anastomoses with 0.7 mm (0.0-2.1 mm) in diameter. The placental territory discordance was 0.17 (0.02-0.40) and the ratio of umbilical cords insertion to the longest placental diameter was 0.82 (0.34-0.99). Conclusions The pathogenesis of sTAPS might result from slow and chronic blood transfusion from donor to recipient through a few minuscule vascular anastomoses in the placenta. In all monochorionic twins, especially sIUGR cases, MCA doppler should be monitored closely in the second and third trimester, in order to diagnose and manage sTAPS in time.
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Objective To evaluate the feasibility,safety and short-term fetal outcome of ultrasoundguided percutaneous microwave ablation for selective feticide in complicated monochorionic twin pregnancies.Methods Twenty-two patients who underwent microwave ablation for selective fetal reduction in Peking University Third Hospital between July 2015 and June 2016 were retrospectively studied.Surgical complications,fetal outcomes and neural development at age of 60 days were recorded.One-way ANOVA,Mann-Whitney U test,Chi-square or Fisher's exact test was used for statistical analysis.Results Indications of the 22 patients for selective feticide included five cases of twin pregnancy with one anomalous fetus,five cases of severe twintwin transfusion syndrome (TTTS),three cases of twin reserved arterial perfusion (TRAP) and nine cases of selective intrauterine growth restriction (sIUGR).All surgeries were successful under regional anesthesia.Four pregnancies (18.2％,4/22) ended in miscarriage following surgery,three of which were caused by intrauterine fetal death (13.6％,3/22) and one by premature rupture of membranes before 26 weeks of gestation (4.5％,1/22).Totally,18 babies were born alive at an average gestational age of (35.5 4.2) weeks (26～40 weeks+2) and with an average birth weight of (2 380.778) g (800～3 430 g),and four of them were preterm infants less than 32 weeks of gestation.Except for one extremely low birth weight infant,whose gestational age was 26 weeks at birth and birth weight was 800 g,died two days after birth,17 infants were discharged alive,giving an neonatal survival rate of 17/18.The total fetal survival rate was 77.3％ (17/22).Polyhydramnios,placenta location,and position of the fetus being aborted showed no significant effect on miscarriage or fetal survival rate (all P＞0.05).No severe maternal complications occurred.No brain injuries were detected by imaging examination in 17 infants who were followed up to 60 days of age.Conclusions Ultrasound-guided percutaneous microwave ablation can be used for selective feticide in complicated monochorionic twin pregnancies.Further studies are needed to evaluate its effects on long-term fetal outcome.
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Objective To compare the outcomes of selective feticide by umbilical cord ligation (UCL),bipolar cord coagulation (BCC) and radiofrequency ablation (RFA) in the treatment of complicated monochorionic twins.Methods We retrospectively analyzed all cases of complicated monochorionic twin pregnancies treated at Peking University Third Hospital from August 2008 to December 2014.The indications for surgery included severe twin-to-twin transfusion syndrome (TTTS),selective intrauterine growth restriction (sIUGR) (type Ⅱ and Ⅲ),twin reversed arterial perfusion sequence (TRAP) or discordant anomaly.One-way ANOVA,LSD t test,Mann-Whitney U test,Chi-square or Fisher's exact test were used for statistical analysis.Results (1) A total of 68 patients chose selective feticide by different techniques,including fetoscopic UCL (n=18,UCL group) and ultrasound-guided RFA (n=46,RFA group).The other four patients treated by bipolar cord coagulation (BCC) were excluded.The maternal age,proportion of assisted reproductive technology,indications,gestational age and mean birth weight all showed no differences between the two groups (P＞0.05).One case of anterior placenta was found in UCL group,fewer than in the RFA group (27 cases,36.9％)(x2=4.853).No fetal loss occurred within two weeks in UCL group,but there were seven cases (seven cases,15.2％) of earlier fetal loss in RFA group (x2=4.952).The median operation time was (63.2±22.5) min in UCL group,and longer than in the RFA group (33.3 ± 11.4) min (t=5.165),all P＜0.05.(2) The gestational age of TTTS and TRAP patients for feticide was older than patients with sIUGR and discordant anomaly [(22.7± 3.0),(22.8±3.2),(20.3 ± 2.5) and (20.4± 3.6) weeks,respectively,F=2.957,P=0.040].Fetal loss rate within two weeks in patients with discordant anomaly was higher than in other groups (4/11 vs 1/10,0/23 and 1/15,P＜0.05).The survival rate,gestational age at delivery and mean birth weight showed no significant differences among the four groups.(3)Compared with feticided fetuses at the upper uterine cavity,the fetal loss rate was higher,and the operation time,gestational age at delivery,birth weight and neonatal survival rate were lower than those performed at the lower uterine cavity,but the difference was not significant.Conclusions RFA provides similar outcomes of selective feticide in complicated monochorionic twins compared with UCL,while RFA is easier to operate.
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Objective To evaluate the effect on maternal blood dilution of fetoscopic laser occlusion of chorioangiopagous vessels (FLOC) in treating twin to twin transfusion syndrome(TTTS). Methods The clinical data of 71 cases of TTTS who had FLOC in Peking University Third Hospital were reviewed. Fluid intake, blood pressure, heart rate, red blood cell count, hemoglobin and hematocrit in perioperative 24 hours were analyzed. Results (1)According to the Quintero staging, 9 cases were stageⅠ, 24 were stageⅡ,28 were stageⅢand 10 cases were stageⅣ.(2)The average operation time of FLOC was (64.0±16.3) minutes. One case had placental abruption after the procedure;one had placental vessel rupture and 6 women refused to take blood counting. These 8 cases were excluded and 63 cases were included in the study. (3) The perioperative bleeding volume was 3 (1, 5) ml, and the volume of fluid intake, urine, amniotic fluid drainage and net fluid intake in the perioperative 24 hours was 2 050 ml(1 530 ml, 3 700 ml), 2 300 ml (1 100 ml, 3 500 ml), 1 900 ml (1 400 ml, 2 700 ml) and -1 760 ml (-100 ml,-3 350 ml), respectively. There was no significant difference between maternal blood pressure or heart rate preoperatively and postoperatively.(4)The maternal red blood cell count [(3.47±0.36)×1012/L versus (3.01± 0.37) × 1012/L, P=0.000], hemoglobin [(107.8 ± 12.1) g/L versus (95.1 ± 11.2) g/L, P=0.000] and hematocrit [0.313(0.238, 0.387) versus 0.276(0.213, 0.800), P=0.000] decreased significantly 24 hours after FLOC.(5) The postoperative hematocrit decreased more in the group which the amniotic fluid drainage volume was 2 000- 3 000 ml than that in the group which the amniotic fluid drainage volume was 1 000-1 999 ml. Conclusions The blood dilution can not be ignored after the FLOC in TTTS patients. The more the amniodrainage volume during the FLOC, the more the maternal blood dilution would be. It might result from amniodrainage during the FLOC, improved maternal-placenta circulation and tocolytics used after FLOC. More attention should be take about maternal cardiac function and complications related with anemia after FLOC.
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Objective To discuss the relationship between repetitive variable deceleration with a short interval (RDSI) in labor and neonatal acidosis.Methods One hundred and seventy-seven electronic fetal heart monitoring (EFM) patterns within one hour preceding delivery in term singleton pregnancies were collected in Peking University Third Hospital between February 2011 to October 2013.Continued EFM were recorded before delivery.Analysis was conducted on general information of both mothers and babies,including pregnant complications,duration of labor,cord and placental factors,nature of amniotic fluid,Apgar score and neonatal cord blood gas.RDSI was defined as that over 50％ intervals between two decelerations (the end of the last deceleration to the beginning of the next one) ≤ 60 s which appeared repetitevly in a period of 20 minutes.Independent sample t test,rank sum test,Chi-square test and Fisher's exact test were applied for statistics and receiver operating characteristic curve was obtained from the information of those with RDSI.Results Twenty-four of the 177 women with RDSI were assigned to the study group (24 cases,13.6％) and the rest 153 cases without RDSI to the control group.Background information of women in the two groups was comparable according to the maternal age,gestational weeks at delivery and duration of labor (all P ＞ 0.05).The occurrence of meconium stained amniotic fluid in the study group was higher than that of the control group [16.7％ (4/24) vs 5.2％ (7/153),x2=5.204,P=0.045],while the pH and base excess value of the neonatal blood gas in the study group were lower [7.20 (7.13-7.28) vs 7.29 (7.25-7.33),Z=-4.490;-6.10 (-4.67 to-9.62) mmol/L vs-3.20 (-4.90 to-1.55) mmol/L,Z=-5.044;P ≤ 0.01] resulting a higher rate of neonatal acidosis [50.0％(12/24) vs 7.8％ (12/153),x2=31.456,P ＜ 0.01].No significant difference was found in the incidence of neonatal asphyxia between the two groups.The area under the curve was 0.774 (95％CI:0.579-0.969).Conclusion RDSI in labor might indicate a high risk of neonatal acidosis.
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Objective To evaluate the placental characteristics in monochorionic (MC) twin pregnancy with selective fetal growth restriction (sFGR). Methods Fifty-five placentas from women with MC twin pregnancy were included, who had terminated pregnancy in the Peking University Third Hospital between June 1, 2013 and June 1, 2014, including 23 cases with sFGR and 32 uncomplicated cases as control group. We perfused the placentas within 24 h after delivery, and pigment of four different colors was used to perfuse the umbilical arteries and veins of both twins and determine the types of vascular anastomosis. Umbilical cord insertion, placental territory discordance (PTD, the territory difference between two placentas/the bigger one), and the type, number and diameter of placental superficial vascular anastomosis were analyzed using two independent samples t-test, nonparametric test,χ2 test or Fisher's exact test. Results The PTD was 0.60(0.10-0.80) vs 0.22(0.00-0.90) in sFGR group and control group (Z=-3.913) respectively, and the proportion of placenta with uneven share was 91.3%(21/23) vs 50.0%(16/32) (Fisher's exact test), which were significantly higher in sFGR group (both P 0.05). The number of AA, AV and VV anastomosis in sFGR group and control group was 1.0 (0.0-2.0) vs 1.0 (0.0-4.0), 3.0 (0.0-10.0) vs 2.0 (0.0-5.0), and 0.0 (0.0-1.0) vs 0.0 (0.0-3.0) (Z=-0.256, -0.142 and -0.123);the total diameter of AA, AV and VV anastomosis was 2.7 (0.0-7.0) vs 2.2 (0.0-9.7), 4.0 (0.0-13.7) vs 3.4 (0.0-11.5), and 0.0 (0.0-7.9) vs 0.0 (0.0-7.1) mm (Z=-0.070, -0.087 and -0.087);there were no significant differences between two groups (all P>0.05). The total number of all anastomosis was 3.5 (0.0-10.0) vs 3.5 (0.0-6.0) (Z= - 0.567); the total diameter of all anastomosis was 6.9 (0.0-22.4) vs 5.9 (0.0-17.1) mm (Z= - 0.556); there were no significant differences between two groups (all P>0.05). Conclusions Placental sharing discordance and non-central cord insertion may be the risk factors for MC pregnancies complicated with sFGR.
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Objective To study the clinical effect of fetoscopic laser occlusion of chorioangiopagous vessels (FLOC) in treating twin to twin transfusion syndrome.Methods The clinical data of 44 consecutive cases of twin to twin transfusion syndrome (TTTS) who had FLOC in the Department of Obstetrics and Gynaecology of Peking University Third Hospital were reviewed and analyzed for perioperative complications,perinatal outcomes and fetal survival rate.Results (1) Patient characteristics:the mean maternal age was (29±4) years,the median gestational age at TTFS being primarily diagnosed was 20.4 weeks,the median gestational age at FLOC was 21.2 weeks.According to the Quintero staging system,there were 9 cases had stages progressed before the operation.(2) FLOC parameter and intraoperative complications:44 cases all could tolerate the operation; there was 1 case of placenta vascular rupture in the operation,no fetal body injury by laser or placental abruption.3 cases underwent cervical cerclage following FLOC.The average operation time of 41 cases alone with FLOC was (60.1± 15.1) minutes.(3) Postoperative complications:the rate of intrauterine fetal death was 15％ (13/88),the rate of intrauterine growth restriction after FLOC was 5％ (4/88),the rate of membranes rupture less than 28 weeks was 16％ (7/44),the rate of TAPS after FLOC was 5％ (2/44),the rate of membrane sepration after FLOC was 5％ (2/44).(4) Perinatal outcome and survival rate:there were 25 patients after FLOC had delivered in the perinatal period.The average gestational age of delivery was (33.5±2.7) weeks.The donor fetuses survival rate was 88％ (22/25),the recipient fetuses survival rate was 100％ (25/25).The birth weight of donor fetuses was significantly less than that of recipient fetuses (1 631g vs 2 071 g,P=0.016).From Quintero staging Ⅰ to Ⅳ,the rate that 44 cases of TTTS had entered the perinatal period was 4/7,11/14,7/19,3/4; both twins survival rates were 4/7,10/14,5/19,3/4; all the fetal survival rate was 8/14,75％ (21/28),32％ (12/38),6/8,respectively.(5) Compared the early stage (Ⅰ + Ⅱ) with the advanced stage (Ⅲ + Ⅳ),the rates that 44 cases of TTTS had entered the perinatal period (71％ vs 44％) and that both twins survived (67％ vs 35％) had no statistically significance.The rate that all the fetus survived in the early stage was significantly (69％ vs 39％) more than that in the advanced stage.(6) All the cases of neoborn were followed up till 1 month postpartum,the donor fetuses and the recipient fetuses had 12 and 5 cases of cardiac abnormalities respectively,each had 1 case of neonatal death and 2 cases of neonatal white matter damage.Conclusions FLOC for TTTS is associated with a better survival rate.Quintero staging probably does not effectively predict the fetal diagnosis of TTTS after FLOC.When TTTS diagnosed,the sooner FLOC given,the better fetal prognosis had.
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Objective To summarize the treatments and perinatal outcomes of patients with twin-twin transfusion syndrome (TTTS).Methods Seventy one cases of TTTS hospitalized in Peking University Third Hospital from January 1,2007 to December 31,2012 were included into the study.They were treated with expectant therapy,amnioreduction,laser surgery or selective fetal reduction.The relationship between outcomes and different staging or treatment procedures of these cases were retrospectively analyzed,and the differences were compared by analysis of variances,Chi-square test and nonparametric test.Results Twenty-five cases received expectant treatment.The rate that at least one baby survived more than 30 days was 32％ (8/25),and 5/15 of the live babies had neonatal brain injury.Sixteen cases received amnioreduction,of which the rate that at least one baby survived more than 30 days was 4/16,and 3/15 of the live babies had brain injury.Twenty-five cases received fetoscopic laser coagulation of vascular anastomoses.The rate that at least one baby survived more than 30 days was 60％ (15/25),which was higher than that of the expectant group and amnioreduction group (x2=4.938,P=0.045 and x2=5.056,P=0.043) ; the brain injury rate among the live babies was 7％ (2/28),which was lower than that of the expectant group (x2=4.702,P=0.040),but similar to the amnioreduction group (x2=1.490,P=0.320).Five patients received selective fetal reduction operation.Among which,one received fetoscopic cord ligation and delivered one healthy baby; the other four cases received radio frequency ablation,after which one was aborted and three delivered at full term.The rate that at least one baby survived more than 30 days was 12/18 in 18 cases with stage Ⅰ TTTS,which was better than that in stage Ⅲ and Ⅳ (4/17 and 6/18) (x2=4.933 and 2.778,both P＜0.05).The rate that at least one baby survived more than 30 days in stage Ⅳ cases was only half of that in stage Ⅰ (6/18 vs 12/18),and the brain injury rate among the live babies was 4/12,similar to that in stage Ⅰ,Ⅱ and Ⅲ [16％ (4/25),0/14 and 2/11,x2=5.361,P=0.118].Conclusion The prognosis of TTTS is very poor,early diagnosis and early treatment could improve the outcomes.Fetoscopic laser coagulation ensures a relatively higher survival rate and low brain injury rate for TTTS.
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Objective To study the placental vascular distribution of monochorionic (MC) twins with twin-to-twin transfusion syndrome (TTTS) or hirth weight discordance.Methods Twenty-eight MC placentas were injected in Peking University Third Hospital between Feb.2010 and Feb.2011.The vascular distribution type (parallel,crossed,mixed and monoamniotic),the anastomosis of vessels and the placental sharing were recorded.The outcome of pregnancy and the placental characteristics of birth weight discordance (birth weight discordance ≥ 20％) in non-TTTS MC twins were analyzed.Results (1) The outcome of pregnancy:the miscarriage or gestational weeks of 28 MC twins were 20 to 38 weeks (median of 35 weeks).Six cases were TTTS,3 of which received fetoscopic laser occlusion of communicating vessels (FLOC).There were 48 live births,with an average birth weight of (2036 ± 623) g.(2) Type of placental vascular distribution:in the 28 MC placentas,number of parallel,crossed,mixed and monoamniotic type of placental vascular distribution were 4 (14％),14 (50％),6 (21％) and 4 (14％) cases,respectively.No parallel type was found in TTTS.There was no significant difference of vascular anastomosis or unequal placental sharing among the different placental vascular distribution types (P ＞ 0.05).(3) Characteristics of placental vascular distribution in birth weight discordance twins:there were 20 non-TTTS MC twin pregnancies,all of which got live births of both babies.Birth weight discordance equal to or more than 20％ was found in 6 pairs of newborns,while birth weight discordance less than 20％ was found in the rest 14 cases.Ratio of unequal placental sharing was significantly different between the two groups (P ＜ 0.01).There was no significant difference of umbilical cord insertion,placental vascular distribution and anastomosis in the two groups (P ＞0.01).Conclusions Vascular distribution type of MC twins might be related to TTTS.Unequal placental sharing is a risk factor of birth weight discordance in non-TTTS MC twins.